Healthcare Provider Details

I. General information

NPI: 1487788634
Provider Name (Legal Business Name): PLAINVILLE OPTICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 EAST ST
PLAINVILLE CT
06062-2309
US

IV. Provider business mailing address

28 EAST ST
PLAINVILLE CT
06062-2309
US

V. Phone/Fax

Practice location:
  • Phone: 860-793-9378
  • Fax: 860-793-2494
Mailing address:
  • Phone: 860-793-9378
  • Fax: 860-793-2494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License NumberCT1106
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code156FX1800X
TaxonomyOptician
License Number001471
License Number StateCT

VIII. Authorized Official

Name: JONATHAN LINDBERG
Title or Position: OWNER & LICENSED OPTICIAN
Credential:
Phone: 860-793-9378